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Kharon’s Blog

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The importance of aviation in Australia cannot be under estimated and Kharon has substantial experience in this field. Being a professional aviator, for many years, Kharon has the wisdom to discuss a range of matters affecting both Australian and world wide aviation.

Kharon posts here on a regular basis and you can read other posts on the PAIN blog site.


#pelAir and Karen Casey:

#97

In the Supreme Court of Appeal;  21 & 22nd Nov.

In the Supreme Court of Appeal, between Nov 21 – 22 will stand Karen Casey. A staggering seven years have passed since the ditching of her aircraft, at sea. This singular event has been examined and dissected through:-

•  CASA Special Audit.
•  Chambers Report
•  ATSB First Investigative Report.
•  NTSB Canadian Report.
•  Senate Inquiry and Recommendations.
•  ASRR.
•  Current Second ATSB Investigation.

The results have been less than satisfactory, ‘Zero outcome’ is probably a better descriptor.  This sorry indictment has dragged on through a change of Australia’s government; a change of the ATSB head and through two previous heads of the CASA. Despite the efforts of several Senators and a minister, nothing of any consequence has changed. Although there was hope of questions, which demanded answers, being asked of ATSB last Estimates; Sen. Cameron expected to start proceedings – however – ATSB slipped through the net.

The ‘second’ report into the incident has been tarnished by the actions and attitude of certain ATSB officers; which, stand alone, without the ‘second’ report, should be enough to provoke a second Senate inquiry. But to delay the report until after the Casey appearance at the court of appeal is despicable. The report itself may be of no benefit to Karen now; probably would not even be admitted into evidence – it could however; if it were ‘honestly done’ provide her counsel with data to support argument.

To me, the truly disgusting thing is that CASA walk away from their despicable behaviour Scot free, well paid, well fed, happy within their sheltered workshop, supported by government. With the full knowledge that their lives will remain secure, comfortable and trouble free; with an unlimited amount of ‘get-out-of goal-free cards’. Make no mistake, the CASA can, does and will in the future continue to enjoy being fully unaccountable to the parliament, the  law, man; or, the gods themselves.

To me, the truly disgusting thing is that ATSB walk away from their despicable behaviour Scot free, well paid, well fed, happy within their sheltered workshop, supported by government. With the full knowledge that their lives will remain secure, comfortable and trouble free; with an unlimited amount of ‘get-out-of goal-free cards’. Make no mistake, the ATSB can, does and will in the future continue to enjoy being fully unaccountable to the parliament, the law, man; or, the gods themselves.

Karen Casey has non of these advantages; injured, in constant pain, unwell and unable, no matter how willing, to support herself. From proud, independent, life loving flight nurse to ‘dependent’ and left to fight the might of these agencies and the ‘insurers’ alone; to Australia’s everlasting shame..

No matter; there’s little I can do or say which will make a difference – hells bells, the bloody minister and the Senate combined failed to dent the monolith. But it intrigues me that a government operation can tell a minister, a Senate committee, three inquiries and an industry to Fuck off – and get away with it. Makes a hellish statement on the state of a nation, a mockery of parliament and beggars the constitution. Abandon all hope of whatsisname fixing it all up, spoiling the manicure with dirty hands or disturbing the immaculate hair-do with concern for one helpless individual.

Aye well; we can wish Karen all the best in 10 days time; which is, by the by, of neither intrinsic or practical value.

Selah.


Bravo – Finally, some sense from two Prune posters.

11. Feb, 2015

All very Hi tech and the elves are going nuts.  So, while we wait:-At long last, after 3181 posts, sweet logic, pragmatic professional thinking and cool sense prevail; finally.  Halle-bloody-lujah…Cool..


Ian W – Pprune – At one stage in my ‘career’ I qualified as an ISO-9000 auditor. One of the things that was expressed to me during the training was that procedures were not required for everything, only where it was really essential the procedures were not varied. Or to put it another way one of the more experienced QA instructors said:

You go to audit some companies and they have several tables all covered with procedure manuals 2 or 3 deep. You go into others and they hand you a single slim folder. You know immediately which company actually follows their procedures.

I think that this has application in the aviation world. Less by rote procedures and more capable personnel will make a better more professional airline which in the long term will be safer and more profitable.

Unfortunately, that message has not percolated through to ‘management’ and tickboxes and inhibition of original thought are seen as the way to do it. That inevitably leads to the:

if there isn’t a procedure for it – you are not allowed to do it‘; and,

I have learned all the procedures in the manual and the boxes have all been ticked, so I don’t need to know anything else.’


Q0283 @ Pprune 1nvestigative approach taken by the KNKT/NTSC ?


What I would like to understand is the huge difference between how the AirAsia and the latest TransAsia accidents are treated by the respective national authorities (both acting under ICAO Rules).

In the AirAsia case the (investigation) authorities have published few preliminary facts (radar, FDR and CVR data). But have published some short ‘final opinion’ conclusions( {we know what happened} “ we have the ‘key‘ “ – and – “it was not a suicide”).
In the TransAsia case the (investigation) authorities have already published many preliminary facts (radar, FDR and CVR data). And have published a ‘preliminary factual’ conclusion (one engine out and the second good one shut down too).

From a professional personal point of view you learn much much more from getting the preliminary facts yourself, struggle with them to find probable cause and contributing factors, and then compare these when preliminary, interim and final reports are published. The main learning moments being where the professional official report either confirms or rejects your professional personal conclusions.

From that professional viewpoint you can only be very very happy with the approach taken by the Taiwanese ASC. And at the same time negatively surprised by the approach taken by the Indonesian KNKT/NTSC.

In context, the Taiwanese ‘political’ risks appeared to be much greater than the Indonesian ones. Declaring the pilot a hero ( while keeping the ‘from hero to villain pilot’ case after rolling the 747 in mind ). Possibly shutting down the good engine too (keeping the UK 737 case in mind). And the mainland Chinese passengers (keeping general politics and MH370 emotions in mind).

In the Indonesian case no-one, not a single mention on PPRuNe I think, suggested a suicide. And no-one expects an investigation team to have the ‘key’ in an early stage. There is a lot of information that can be published without having any political overtones. Publishing the MH370 take-off fuel weight for instance would also have harmed no one, on the contrary one could even say.

Is there a PPRuNe member who has an informed opinion on this. And can give us a better understanding of how the Indonesian investigation might view its own QZ8501 approach.

Nice to see the ‘real deal’ at work, always a pleasure; thank you gentlemen….Thumbs up…..

Toot – toot….Big Grin…..

 9. Feb, 2015

Quote:


“Unfortunately accident investigation is being driven by organisational theory and bureaucrats with the end result being sub-standard reports like Pel-Air.”

Good point: and, in a normal world, it would be a legitimate topic for civilised peer discussion. But for Pel-Air at least I reckon it could stand a little expansion. For sake of argument lets ‘assume’ (we may, safely take a small risk) that the ATSB investigators were competent and they followed the well trodden path a ‘bog-standard’ accident investigation should take. The report even allowing for the ‘theoretical’ should have got us to within a bulls roar of the why, how and wherefore; it may have even provided some peripheral causal reasons which assisted in defining the desired end result – risk mitigation. There were several valid, not overly theoretical issues which did make it into the final report; RVSM, flight and fuel planning, lack of operational support, fatigue, lack of 20.11 training, etc, (don’t ever forget, CP responsible for all) from which a reasonable operator could make adjustments to SOP, in an effort to mitigate the risk of reoccurrence. I don’t have too many problems with the notion of ‘theoretical’, provided it can be translated, by the operator into practical fixes. So far the ATSB investigators are free and clear, reputation intact.

It’s what happened next that got me cranky (just a bit): Sarcs at # 2653 has gone to some trouble to point out the direction a perfectly serviceable accident ‘report’ was being driven and IMO, in deference to the law, he has treated the ‘aftermath’ with kid gloves. For the thinking man, joining up the remaining dots to form the final picture is a piece of cake. The Senate inquiry surely got there.

It has been a long, slow difficult process since then: the Senators didn’t waste too much time, their report was out in a timely manner; but since then, purgatory. Forsyth, then TSBC, then miniscule response, at the end we get (headline) “Pel-Air to be reinvestigated”.

The academics and theory of ‘how’ to investigate an incident which happened, what ? five years and a bit ago have not changed and have had precious little to do with what transpired after the IIC report was ‘edited’ and produced. It’s not Dr. John we need, but a judicial inquiry supported by the AFP, I’d even settle for the Senate committee as a DIP to manage yet ‘another’ inquiry (how many do we need). But FCOL someone with some juice do something – anything. Anything bar giving the true villains more time to clean up and hide the evidence which should rightfully hang the lot of them. The IOS has been very, very patient: thus far.

The comment below followed an article published by Australian Flying re the re Pel-Air MKII.

Quote:


Sceptical • 10 days agoHead of Aviation Investigations at the time of the report? Ian Sangston.Told of factual errors prior to release of the report? Ian Sangston.

Head of Aviation Investigations for the new report? Ian Sangston.

Conflict of interest?

Just about says it all. The background noise? Oh, that’s the playroom clock; tick, tock, tick, tock.

 8. Feb, 2015

Thumbs upFrom Planetalking blogpiece:- It looks like TransAsia is in really big trouble over crash


Ben Sandilands  Posted February 7, 2015 at 1:53 pm | Permalink

An experienced pilot who doesn’t wish to comment in his own name or using an alias has offered the following perspective, which I think makes some persuasive observations:

When I did my multi engine rating, my instructor strongly emphasised that the actions after engine failure must be done quickly. I’ve had discussions with other multi engine rated pilots who all sing from the same songsheet & there’s almost a macho mentality that says ‘if you can’t do it quickly you shouldn’t be flying one’.

They’re wrong. It’s stupid. People die as a result.

Agreed that pilots ought to, on an ongoing basis, practise & be familiar with engine out procedures.
Agreed that pilots ought to think about what they will do in the unlikely event of an engine failure after takeoff, before every takeoff.

But, the training mentality that pilots must accomplish the engine out procedures with haste is the problem.

After engine failure, the first & main priority is to control the aircraft. The TransAsia pilots appear to have not done this.
The subsequent actions, identifying the engine which has failed, ought to be done carefully. The TransAsia pilots appear to have not done this.
An engine failure after takeoff is stressful. That’s even more reason why pilots should be trained to take a pause before identifying the failed engine.

While I acknowledge that engine failures are practised in a simulator, there’s a huge mental difference between being in a sim & knowing that you’re physically safe, compared to being in a plane with big scary objects outside and knowing you might die.

If the ATR engine auto feathers, then it’s almost idiot proof. Almost.
You would just have to maintain control of the aircraft on the single working engine, pretty much without any additional actions.
If you were basically competent in hand flying an aircraft [a topic for another day] then you’d be looking every bit the hero.
But throw in a rushed engine failure check in a stress situation & you’d have the perfect ingredients for a crash.

As you’d know from crash reports, this is not the first of this type of accident & certainly won’t be the last.

As a passenger, I’m always a little nervous until there’s a goodly amount of height between me & the ground. I know how pilots are trained!


MTF…P2

7. Feb, 2015 The unspeakable Pprune

The new web site – HERE – is a Work in Progress – Comments are open for the published posts…Patience required, more to follow…Cool

We note the unspeakable Pprune web site continues it’s mindless descent into becoming a bland, politically correct, edited, moderated and censored mouthpiece for the ‘vested interest’ society.  At least on the Australian forums; populated by resident Trolls who have only one agenda – continue the party line.  There is so much hidden and so many heads stuffed in the trough which must be protected that any semblance of truth, or vestige of criticism must be snuffed out.  Of course no one dare say you are upsetting ‘the powers that be’ with accurate reporting and explanation of what is going on; no, far too gutless for that sort of thing.

The thing the PAIN association finds most concerning is the total apathy of the Australian aviation industry, reflected on the UPP.  Whether this ennui has developed after years and years of frustration; or, fear of retaliation or from any of the many other subliminal reactions should be a cause for government concern; the almost total lack of investors willing to support a once thriving industry is slowly killing a potential source of employment and taxable revenue.

Lack of political will to affect change has been a feature for the past three decades.  There have been some 20 odd investigations, inquiries and ‘reports’ made.  All serious, expensive and damning of the way the regulator has performed.  The three most recent have generated almost 70 serious recommendations clearly indicating that the regulator has made an absolute shambles of a 23 year, 250 million project to modify the regulations.  The reports also indicate a serious, deep rift between regulator and regulated, which will need more than a band aid and a kiss from Mum to heal.  So what has happened after the last go around?– well, nothing really.  A little window dressing, a little rhetoric, but apart from that, SFA.  The new director is embroiled in a battle with his 2IC who has not only refused to resign, but is determined to continue the McComic madness, actively and openly rallying support within the Golden West Mafia (GWM).  Gods help us, for the Minuscule will not: and; industry sits on it’s arse, desperately avoiding being the one who spoke out of turn, lest they be next.  Pathetic.

But it’s not just the complete absence of political and industry will; Australia has a user pays system and if you want to use the system then you must pay.  The Baksheesh is not of the open, honest kind, but the thrilling clandestine type; where you must join the secret society of Mutual Back Scratchers (MBS).  Like any high powered criminal network, once your in, there is no out.  Not, mind you that many want out; No, the grass is too green, the water too sweet and the thrill of being ‘in’ are all far too alluring.

And so, the grist to the mill keeps flowing: high profile complaint is seduced with sweet offers and membership pleasing deals, too good to be refused.  The riff-raff may be ignored with impunity or hammered down by the sheer power of the Iron Ring, which may be used to decimate political will, influence a government and pervert the result of any honest report which clearly defines that there is, indeed, ‘something rotten in Denmark’.  Lucky country – #Bollocks.

Aye well, at least here I can have my say, I can even ‘moderate’ fools and trolls off the site.  Can’t wait..Wild… Toot-toot.,,,Thumbs up,

Beware world – the ex director and author of the great Australian aviation tragedy McComic  is vying for a seat at ICAO.  First Australia, then world domination by a man who created the infamous Cathay Pacific 49′ ers saga, engineered the great Pel-Air duck up, compromised the industry complaints commissioner, emasculated the Australian aviation industry and is under investigation for breaches of the sacred Transport Safety Act (TSI) and other ‘matters’, such as lying through his teeth, under oath to Parliament.


Steve Creedy – “AUSTRALIA’S licensed aircraft maintenance engineers (LAME) lobbying hard in Canberra to reverse rule changes they say are illegal and unsafe have been backed in an opinion by high-profile lawyer Bret Walker.”


Now, of all the stultifying, mind numbing, self immolating things anyone can do, reading the aviation regulations of your own country ranks up there with cooking shows; but to read those of another country ranks number one in the self harm games.  But; if there are people out there in Tweep land who can bear to delve into the mysterious world of Australian aviation regulation, they will get quite a shock.  Here is a primer:-

The USA and NZ manage to deal with pilot licensing (Part 61) in about 60 pages of sane, practical regulation written in language as close to plain English as it is possible to get.  Australian part 61 boasts some 1600 pages to cover the same topic, this supported by a ‘Manual of Standards’ (MOS) of similar, titanic proportions; these manuals are based in the most confused, tortured legalese possible, filled with blood curdling threats of criminal prosecution and all offences are strict liability.  Strict liability places a reverse onus, the burden of proving oneself innocent, firmly on the head of the accused.  But wait, there’s more; the rule set is totally bloody useless, unworkable and has horse and cart sized holes in the very fabric.

The same philosophy is applicable to all the CASA regulations which revel in criminal prosecution and sheer volume.  The heartbreak is from a battered industry which has tried to rein in the behemoth of the McComic era rule makers and thus far, not only failed to do so, but has become terrified of it’s own shadow, under the repressive autocracy of McComic and his happy band of catamites.

Think hard Dear World, very hard for if the McComic era lands and takes root in Montreal, not even your daughters gold fillings will be saved in the rapine and pillage of a McComic inspired ICAO slaughterhouse.

Selah.

__________________________________________________________________________________________________

The World at the back of the room!

From one tendentious blogger to another (life member) of the TBA & IOS – Ben Sandilands :ATSB forgets Pel-Air in study of fuel exhaustion accidentsBen Sandilands | Feb 09, 2015 3:32PM | EMAIL | PRINT

Apt illustration from today’s bizarre ATSB recycling of old study

Amnesia can now be again added to the failings of integrity and safety focus in ATSB reports on the repeated release today of its study titled Starved and Exhausted: Fuel Management Aviation Accidents.

It leaves out the fuel management related crash investigation of the century, the one in which a Pel-Air flight was ditched near Norfolk Island in 2009.

But the notification of the study by the ATSB using Twitter is even stranger. It’s recycling the study it published according to the fly sheet in March 2013 and the web page the link to the download takes you was last edited in April 2014.

Among the illustrations in the study is the top of page photo of the retrieval of a Piper Cherokee Six that ditched while conducting inter-island charters between Mackay and the Whitsundays in April 2008.

So strange. If the ATSB can haul an entire Cherokee out of the Whitsunday waters, what really stopped it being sufficiently curious about the ditching the Pel-Air Westwind corporate jet from the water close to Norfolk Island to recover its flight data recorder?

What didn’t the ATSB want to know? Now, in 2015, we know that the ATSB and CASA variously withheld or dismissed serious findings about safety deficiencies in Pel-Air’s operations, owned by the generous Labor and Coalition political donor REX, who lavished completely unrelated and out of character gifts of money to both sides of politics in the same year that a discredited ATSB report into the crash was released.

The optics aren’t good. The ATSB re-releases a report that leaves out the most important fuel management accident in its history at the same time as it is trying to get away with conducting a new review of that Pel-Air rash report it insists is fault free.

This is pathetic.

Definitely MTF


Last edited by Sarcs; 10th Feb 2015 at 09:51. Reason: c/o auntypru.com

Quote:
Slatts11, it would appear that Nick got his 15 minutes of fame over the senate inquiry and has now moved on to bigger and better things.

Eddie I’m not so sure about that, have a look here:

Quote:
Senator Xenophon queries political donations by regional airline Rex INDEPENDENT senator Nick Xenophon has called large political donations by listed regional airline Rex “incredibly baffling” and said he would be buying shares in the company so he could press board members on why the donations were made. Mr Xenophon, who led a Senate committee inquiry into much criticised government investigation into the crash of a Rex-owned passenger plane off Norfolk Island, said the airline had an “obligation” to disclose why the donations were made.

Between July and November 2012 — amid a three-year inquiry into the Norfolk Island crash — Rex made a $250,000 donation to the ALP, $95,700 to the federal Nationals and $40,000 to the Liberal Party. This made the small airline one of the biggest political donors in the country.

“Rex is a public company and it had an obligation to explain whether even one (word) regarding the crash was spoken with any of the political parties,” Mr Xenophon told The Australian.

“This largesse to political parties is inexplicably baffling and I will be buying some shares in Rex and asking them to explain it.”

Rex spokeswoman Alicia Chapple has declined to respond to repeated questions from The Australian this week regarding the donations and other matters, saying that the airline did “not see the need to devote additional resources to this matter”.

The airline had earlier incorrectly claimed it had made no donations to the LNP; however, when shown otherwise, Ms Chapple said the airline had meant it had made no donations to the Queensland LNP.

Of particular interest was Rex’s $250,000 donation to the federal ALP given the airline was a highly vocal critic of the Labor government.

In 2013 Rex publicly said the ALP was “hellbent” on destroying regional aviation and “along with it pretty much the rest of the economy”.

Mr Xenophon said it appeared to defy reason why Rex would donate heavily to a government it would shortly afterwards describe as “destroying its industry”.

“Perhaps Rex had a case of Stockholm syndrome?” he said.

In 2009 a Rex aeroplane — operated under the group’s Pel-Air brand — ditched into the ocean with six passengers on board, badly injuring one.
A lengthy Australian Transport Safety Board investigation blamed the Pel-Air pilot involved in the crash but failed to mention 57 breaches or “serious deficiencies” at Pel-Air.

Mr Xenophon headed a Senate committee inquiry into that botched investigation, which led to the federal government last month calling on the ATSB to reopen the investigation.

Rex has also come under the spotlight after it was last year awarded a series of key Queensland government contracts which had previously been held by Cairns-based rival Skytrans.

And here yesterday also from the Oz: Lawyer and senator back engineers in aircraft maintenance dispute

Quote:
Officials from the Australian Licensed Aircraft Engineers Association have briefed politicians from all parties on the issue and received initial support from independent senator Nick Xenophon for a disallowance motion aimed at reversing Civil Aviation Safety Authority amendments to maintenance regulations.Senator Xenophon filed a notice of motion on December 4 for disallowance of the Civil Aviation Safety Regulations Part 145 Manual of Standards amendments relating to specialist maintenance workers.

And as slats said there is the small matter of an outstanding MoP yet to be resolved – Possible imposition of a penalty on a witness before the Rural and Regional Affairs and Transport References Committee or a person providing information to the committee

….& the final washout of the forensic examination of the performance of ASA

Certainly doesn’t appear to me that Senator X has lost interest in matters of an aviation safety nature…

 6. Feb, 2015     Watch out world!
Quote:
Sunny: Net result of CASA corruption and incompetence will be higher insurance premiums for Australian registered aircraft compared to other developed countries.

Which supports the BRB hypothesis that M&M & co seek to decimate the GA industry in this country…

On a slightly different tack I noticed some interesting obs by Dougy in his weekly insight:

Quote:
Editor’s insights 5 February 201505 Feb 2015 Doug NancarrowLots of informed speculation circulating at the moment, including about the CASA board, Qantas and the appointment of a new ICAO Secretary General.

There’s set to be some changes to the CASA board when chairman Allan Hawke steps down in the second quarter. I have assumed up till recently that deputy chair Jeff Boyd would take on the role at that time, but there’s some talk that an entirely new chairman may be appointed. If that’s so then there’s one obvious candidate for the job, but would he want to take it on? Either way, the ‘new’ CASA board needs to be independently proactive and firmly behind the new DAS, to help him stay on song in his relationships with industry and with those powerful CASA elements that can be obstacles to change.

The other thing the CASA board and the Minister’s office should be looking at is reconvening the team that put together the ASRR Report, now more commonly known as the Forsyth Report. We’re rapidly approaching the one-year mark since the report was delivered to the Minister and given a pretty general industry view that not much has been done about the report’s recommendations it would be a damned good idea for the trio who put it together to give us a report on progress – or lack of it.

On the Qantas front there’s been some chatter that chairman Leigh Clifford might have decided that he’s had enough after seven years at the helm. If that turns out to be the case then it could have significant implications for CEO Alan Joyce who has worked very closely with Clifford. Even more so if rumours about a Clifford replacement also turn out to be true.

And we’ll know about the second week of March if Australia’s official nominee for the top job at ICAO has got in. The contest for the ICAO Secretary General position, now in its final days, is between former CASA DAS John McCormick and a Chinese nominee who has been running the human resources side of things in Montreal. Regardless of any residual industry sentiment about J Mc it would be excellent to see an Australian running the show up there.

Despite the extraordinary distractions in Canberra right now, it seems likely that the Senate star chamber will shortly be targeting unresolved aviation issues such as the Pelair ditching. And aviation entities such as Airservices and ATSB are not out of the woods yet either. I fully understand the need for vigilance with regard to the performance of these aviation bodies, but it can get out of hand and become a huge distraction from the real work they are charged with performing. Just look at the way the NSW ICAC has run amok in recent times. Dig deep and hard enough and you’ll always find something amiss, but you will run the risk of turning a target into an organisation focused almost entirely on its own survival instead of the job it should be getting on with. Finding the right balance is not something
Senate committees have in mind. They want blood.

Hmm interesting… However it was the 5th paragraph that almost made me vomit…

“…Regardless of any residual industry sentiment about J Mc it would be excellent to see an Australian running the show up there…”

…but then I thought nahh Dougy’s got his tongue fairly stuck in his cheek..

I also did a small exercise and passed Dougy’s missive around and here was a couple of (anonymous..) responses…

“…If Doug and I were in the same room I’d suggest that McCormick’s behaviour in the Pel-Air episode the lying to protect CASA at the expense of air safety and the victims of the crash should render him ineligible…I would endorse his suggestion of a Forsyth review…”

“…Agreed. His integrity is such that he simply can’t occupy such a position…Then imagine how awkward it would be if Aust aviation was to be downgraded as a result of deficiencies on his watch…Too many skeletons…”

But my personal favourite was this one…:Lock up your daughters, hide your gold.

Which surprisingly heavily supported a twitlonger piece I had been working on when the J Mac ICAO secgen story was covered by the MMSM the Oz – Watch out world!:

Quote:
CASA chief John McCormick’s ICAO nomination confirmedTHE federal government has confirmed its nomination of the former Civil Aviation Safety Authority chief John McCormick for the secretary-general’s posi­tion at the International Civil Avia­tion Organisation. Mr McCormick finished his term last year amid controversy about the way CASA dealt with the industry and after a highly critical 2013 Senate committee ­report into the authority’s role in an investigation of the 2009 crash of a Pel-Air air ambulance off Norfolk Island.

The Aviation Safety Regulatory Review report, chaired by ­industry ­veteran David Forsyth, called for sweeping reforms after criticising CASA for taking too hard a line and maintaining an adversarial approach to the industry, which had lost trust in the authority.

The report was ordered by Deputy Prime Minister Warren Truss in response to industry criticism of CASA and concerns about the adequacy of the Aus­tralian Transport Safety Board’s investigation into the Pel-Air ditching.
It accused the regulator of adopting “an across-the-board hardline philosophy, which in the panel’s view is not appropriate for an advanced aviation nation such as Australia’’.

The government said it would investigate 36 of the review’s 37 recommendations.

Mr McCormick’s nomination appears to have been revealed at an ICAO seminar last year by the Department of Infrastructure and Regional Development’s inter­national standards director, Jamie Thomson.
A spokesman for Mr Truss this week confirmed the endorsement of Mr McCormick to replace Raymond Benjamin when his term expires on June 30.

“Having an Australian serve as ICAO secretary-general would present a unique opportunity to further enhance Australia’s international reputation in maintaining the safety and security of aviation and for Australia to continue to influence international aviation policy development,’’ the spokesman said.

“Mr McCormick has over 30 years of experience in the aviation industry as CEO of CASA, a senior pilot and airline manager, as well as experience in the RAAF. No other candidate for ­secretary-general of ICAO can bring the same experience and qualifications to the role.’’

“…This consummate Sociopath – almost single-handedly – in 5 (long) years has nearly decimated the Australian GA industry…”

Remember this…??

https://www.youtube.com/watch?v=K0pJv6DNzuo

Buyer (ICAO) beware!

It is absolutely staggering how the more we discover with the PelAir duck-up of the cover-up the more entrenched the Mandarins & the Pollywaffles become in obfuscating the issue – in other words they are flat out in denial… And this is despite the rest of the world acknowledging a long..long time ago that the game was up and the stench emanating from Aviation House and the surrounding precinct was positively rancid…

An excellent example of this was captured in Hansard – from the 24 Feb ’14 Senate Estimates – where the Chair Senator Heffernan said this (in bold) in reply to Dolan’s weasel words…:

Quote:
Mr Dolan : I and my fellow commissioners very carefully went through the contents of the committee’s report and tested it against the information we had available to us in the course of our investigation. There was nothing, in our view, that constituted new and significant information that would lead to a need to reopen the investigation.CHAIR: How did it go from a critical incident to a ‘don’t worry about it’ incident?Mr Dolan : That is a matter we did rehearse with the references committee. In short, our initial assessment of the issue of guidance as to dealing with the situation, weather deterioration and what was planned, we overassessed it as critical at an early stage and by applying our methodologies we concluded by the end of the process that it constituted a minor safety issue.

CHAIR: Can I commend you. You look really well. You look less stressed than you used to for some reason.

Mr Dolan : It is probably the lack of the beard.

CHAIR: With that particular incident of which I just spoke no thinking person would believe that bureaucratic answer. You cannot go from a critical incident to a minor one or whatever it was without something happening on the journey. Anyway, we will not go back there. To any sensible person it sounds like either a cover-up or a balls-up.

And slats11 does not shirk the issues in his excellent contribution the Peeler, CASA, and ATSB – the movie which goes some of the way to chronologically explaining the whole corrupt, sordid tale.

Despite the many twists and turns since the farcical, BASR ATSB final report was released – what is amazing is how the slats11 script has not deviated that much.

Perhaps to highlight this here is a blog piece from the popular US Avweb online publication..:

Quote:
Norfolk Island Ditching: Still Many Questions   By Paul Bertorelli | September 16, 2012If you talk to someone who’s been involved in a serious aircraft accident long enough, they’ll eventually get around to two things: The accident constantly intrudes in the daily thought process and any external description of it—an official accident report or news reports—won’t ring quite true. Experiencing something so traumatic isn’t the same as reading someone reporting it.I thought of that when I interviewed Dominic James over the weekend. James was the Captain on that Westwind that ditched off Norfolk Island on November 18, 2009. At the time, I blogged that the accident report on this one is going to be interesting. Now that the report is complete, I got what I wished for. It’s interesting alright, but for the wrong reasons. This accident appears to be a classic example of the linked chain, but the ATSB’s report simply ignores many of the links, speeding apace to its conclusion: The crew was responsible.

And so it was. The flight crew—James and First Officer Zoe Cupit—had the final vote and sole ability to sunder the accident chain. They failed to do that, but the report itself fails to explain that in some ways, the company, the system and CASA set James up for an accident and left him to his command authority to avoid it. When a perfectly competent pilot throws away a perfectly good airplane, it’s often the result of a mindset patterned by past success and both external and internal pressures. This accident seemed to have all of that. As we reported in today’s news, James is challenging the ATSB report and an Australian Senate hearing on it is planned for early next month. He says he’s not ducking fault or responsibility, but believes the report simply doesn’t give an accurate picture of all the factors involved in the accident.

To refresh, the flight was a Westwind medevac mission with a stable patient from Apia, Samoa to Melbourne, Australia. To save you the trouble of hauling out your atlas, that’s some 2800-nautical miles, almost all of it over water. It’s the distance from New York to Los Angeles, plus another 700 miles. Norfolk Island was the planned fuel stop, a distance of 1600 miles. James said the Westwind had the legs for trips like this, but only if everything went to plan.

For James and Cupit, it didn’t. With good VFR forecast for Norfolk, neither the company’s policy nor Australian regulation required a named alternate, so none was contemplated. In any event, it’s doubtful that one could have been reached. The closest was Noumea in New Caledonia, 400 miles north of Norfolk Island. The Westwind departed with 83 percent of full fuel; mains full, tips empty. Even with the tip fuel, Noumea was unlikely, given the fuel required for climb. When the weather tanked at Norfolk, the crew had no option other than to land there. It couldn’t and ditching was the only survivable option other than a desperation, homemade, below-minimums approach. The airplane simply lacked the capability to do the trip with contingency fuel.

The number of links in this accident chain not covered in the ATSB report are too numerous to cover here. But as James explains it, they’re obvious to him in retrospect. In hindsight, it is clear how this chain of events led him to the decisions he made. On a previous trip, James had been told Norfolk’s automated weather reports were notoriously pessimistic and forecasts for the island were iffy. Other similar aircraft routinely made such trips with no drama, despite Norfolk’s exceptional remoteness. Pel-Air seemed to have a loose relationship with regulatory adherence and CASA failed to oversee the company aggressively, as evidenced by an internal report only recently made public. ATSB never mentioned this report.

Pel-Air airplanes routinely operated in or through RVSM airspace, but the Westwind wasn’t RVSM equipped, according to James. Controllers would give the flight a bye on RVSM if they could climb to FL390, which the Westwind could do only if light, thus the decision to leave tip fuel behind.

Noumea was potentially a paper alternate, but James said the local authorities there didn’t want Pel-Air airplanes arriving because they lacked TCAS II and GPWS, not to mention RVSM. The accident airplane had just had TCAS and GPWS installed, but James and Cupit had never seen it and hadn’t been trained in its use.

The ATSB made a great deal of discussing James’ fuel planning, especially the oceanic technique that routinely requires points of no return and/or critical points, which are continuation decision thresholds when few or no alternates are available. The ATSB conceded that based on the forecast, an alternate wasn’t required and that the crew had enough fuel for a flight that proceeded normally, but no contingency for a de-pressurization event that would force the airplane to lower, less fuel-efficient altitudes. If the drift down happens in the wrong place, the range can dwindle to the point of neither being able to return to the departure nor reach an alternate. James insists his fuel load covered this and when he asked the ATSB for its fuel calcs, they declined the request. He had the data reviewed independently to confirm his calculations.

Even with the good forecast, James got an updated METAR for Norfolk from Fiji ATC. The controller misstated the ceiling as 6000 feet rather than 600 feet. A later corrected METAR relayed via HF was garbled in poor atmospherics at dusk. James couldn’t explain why he didn’t receive it, but he knows he didn’t. Fiji refused to release the audio tape of the transmission. “There’s no way you sit on your hands for an hour after getting a METAR like that,” James said. “You’d have to be a suicidal maniac.”

That missed METAR may have been the final or most critical link in the accident chain. Once the Westwind passed Fiji, it was committed to Norfolk, save for a brief diversionary window to Noumea. I like to think if I’d been in that cockpit, I’d have surely had the threat and error management thing going on and would have diverted sooner, just as any competent pilot should. Maybe you think the same thing. The reality is that given the circumstances, I can imagine myself being sucked down the same dark hole James and Cupit found themselves in. For me, personally, that’s a creepy truth, but a truth nonetheless.

Later in the week, I’ll take a look at another accident that is eerily similar to this one. It occurred 42 years ago in the Caribbean.

See what I mean a few more dots & scenes for the movie script but the basic plot remains the same.

While on the Avweb it is worth going to the PAIN comment at the bottom of the page as it is extremely pertinent in light of the Ferryman’s Cui Bono? piece on Flight Nurse Karen Casey’s upcoming court case…:

Quote:
Flight Nurse comment from Planetalking blog:  Karen Casey Posted November 4, 2012 at 3:49 amWhen will truth trump cover-ups that are with laced with selfish intent to save ones posterior? How ridiculous to have so many broken rules in an- audit, yet almost get away with it. There is a reason for the truth that is emerging, it’s for air safety & the failure of our regulator & investigative bodies results. It has been the survivors that have been the seekers of the real deal. What a disgrace. With both our Chief Commissioners under the microscope now, the amplification of this ordeal is finally happening. CASA & ATSB have a lot to answer for, dragging this on for selfish intent is criminal & at the least cruel to all on board. The coverup is surfacing and all will be revealed about the incompetencies of all parties involved. How unprofessional this has all been. How disappointing in the treatment of the people who have experienced hell from impact till now with our own government bodies involved. Does our government have enough integrity to investigate the individuals involved and actually DO something about this rather than just go around in circles. To add insult, let’s just throw in the fact that the ex-Pel-Air chief pilot at the time of the incident now works as an investigator for CASA…please!

“Just stop the B.S & tell the truth.”

PAIN comment: Puts a human face to this sordid tale!

Quote:

Well Sarcs, since Jan 21 to date your revitalisation of the Pprune Norfolk ditching thread has generated 12,000 views. I noted yesterday there were during the afternoon some 700 (650 – 780) ‘visitors’ as against 50 (35-50) ‘members’; a quick review of the members showed 74% non commentators (on anything) the rest were one line ‘snipe’ specialists. except for the two known trolls.

Interesting obs Ferryman and all passing strange from our once dearly beloved Prune... While trolling thru the many volumes (terabytes) of cyber info on MH370 it would also appear that this apparent prune censoring is not isolated to the dreary old downunder/godzone boards…

Take a look at the following quote from John Sampson (extracted from here):

Quote:
Pprune is a well-known aviation themed forum purchased from its British airline pilot owner/initiator/moderator and now operated by a US-based professional media monitoring and moderation company on behalf of vested airline and industry interests. The Pprune moderators’ specialty is now notably in quietly vetting, suppressing and deleting key material – and accomplishing this by surreptitiously banning posters whose technical knowledge and theories are too incisive or of proprietary concern to its proxy forum owners (i.e. not to be made public). The fact that this theory has been actively expunged on numerous occasions (and its poster banned by the Pprune truth-police) gives this theory great credence and credibility. Criminalization of pilots and/or unlawful interference is a much-favoured proposition for the industry – for obvious reasons it can derail litigation costs. However a large-scale calamity based upon a prior accident and subsequent industry and regulatory inactivity is hopefully not “containable”.

Can’t vouch for the veracity of that statement but if only partly true it paints a very disturbing picture on the behind the scenes power games going on at Aunty Pru…

Somewhat for my own perverse amusement and as I am still busy collating/archiving – for more volumes of ‘Top Posts’ from the 2nd closed Senate thread – I will for now continue with the Norfolk thread exercise…

(Ps which reminds we need a new post before it drifts off the page…anyone?? )

Norfolk Island Ditching ATSB Report – ?

_______________________________________________________________________________________

MH 370 – Questions

8. Feb, 2015 Relocated          #MH 370 moved to auntypru  26. Jan, 2015

I agree with P9; as the PAIN network senior 777 captain there are some questions which we have been discussing amongst ourselves, we believe the answers are important.  It is the direct involvement of the ATSB rather than AMSA that provides an element of suspicion which impinges on and detracts from the credibility of any ATSB answer to those questions.  For discussion:-

What was the information the FBI allegedly extracted from Captains personal computer?

Was this alleged information passed to the ATSB?

Was this information the reason why the search area switched further south?

We have discussed these questions at length and cannot reach a sensible consensus.  Any fresh ideas would be more than welcome.

P777.

____________________________________________________________________________________________

More Slats insight @auntypru.

Its worth having another look at the March 2008 audit of PelAir.

1. An audit had been planned in October 2007, but this audit was terminated as the majority of pilots did not submit their logbooks. The audit was rescheduled for 12-13 March 2008. Page 3.

2. PelAir hasd been operating under a Fatigue Risk Manaement System (FRMS) for 11 months. However pilots had not received training in FRMS. This non-compliance was considered by CASA to be an imminent safety threat. On 12 March 2008, CASA issued an immediate Safety Alert, which precluded further operations under the FRMS. On 17 March 2008, PelAir advised CASA the required training had been completed. On 18 March 2008, CASA approved PelAir to resume operations under the FRMS – possibly a record turnaround by CASA. Page 3.

3. There were other deficiencies in addition to the FRMS training. Review of pilots records showed  80% had no evidence of training in emergency procedures (page 4), and irregularities in the renewal of instrument ratings (page 4).

4. On 11 October 2008, CASA formally documented that all active pilots had been trained in the FRMS. Page 45. 

Which should be all well and good.

But it does make you wonder why the 2009 post-crash CASA special audit (only 12 months later) again found serious issues with fatigue and the FRMS. Four pages (22-25) of this 2009 audit deal solely with faitgue management deficiencies.

  • “Most crew itentified a lack of understanding of the FRMS processes, and crews regarded the training as inefficient and ineffective.” Page 22.
  • There was an “FRMS knowledge gap displayed by the pilots.” Page 22.
  • “PelAir have not managed fatigue risk to a standard considered appropriate…” Page 23.

These 2009 audit findings appear at odds with all the training condcuted by PelAir and approved by CASA in 2008, and with CASA approving a return to FRMS operations.

These audit findings also raise questions why the final ATSB report was not critical of CASA’s regulatory oversight of PelAir throughout this period.

 29. Jan, 2015  MH370

From what is in the public domain, it appears the only source of information being used to define the search area is the Inmarsat data. The problem with this data is it generates a multitude of possible solutions, resulting in an enormous search area.

If the current search does not turn up MH370, we will need to either accept it is lost and move on (which would be deeply unsatisfactory), or else accept that the Inmarsat data alone is not sufficient and employ alternative methods to find it.

I believe MH370 was most likely a criminal act – that is, the plane was deliberately diverted, and then flown under human control with the intent to make sure it was never found and would disappear forever. There is a fair bit of evidence that supports this theory. So perhaps we should consider MH370 a criminal act, assume the motive was to minimise the chance that the plane will ever be discovered, and follow that to its logical conclusion.

If you wanted to make a plane disappear, the deep south Indian Ocean is as good a place as any. And you would hope to end the flight in a way that minimised debris.

If you accept the Inmarsat data, then there are two possible scenarios:

1. A flight south with autopilot engaged, fuel exhaustion, and crash – likely with much fragmentation and debris.
2. A flight south under human control, fuel exhaustion, and possible controlled ditching with somewhat less fragmentation and debris.

From a Bayesian perspective, the lack of any debris whatsoever would seem to increase the probability of the second scenario. The lack of debris also favours a location further away from land.

If true, this supports  a plan to take the plane as far as possible in an unexpected direction and avoid it ever being found. So perhaps Thomas Bayes would now suggest we look for the furthest SW point along the 7th arc consistent with the data. Further, should we look at the various unknowns and now input values (or scenarios) that would achieve the goal of the most SW point (i.e. the most remote location).

Coming back to the earlier phases of the flight. Many have speculated that the pacs were turned off to incapacitate the crew / passengers. Time of useful consciousness for non-acclimatised people at FL350 is perhaps 30-60 seconds. There was some talk about a possible climb to FL430, but I don’t recall if this was ever verified.

There has also been speculation about crossing the peninsula at relatively low level. Again I don’t know that this has ever been verified. This hint at a low level flight might be a convenient excuse to explain away the very limited primary radar data after the transponder ceased operating. I wonder however if the plane really did cross the peninsula at a low level. There are several reasons why the “perpetrator” may have *not* wanted to descend:

1. Although sudden depressurisation at FL350 will reliably incapacitate people, it won’t be immediately fatal. For a period of time, this incapacity will be reversible and people will regain consciousness upon descent to a lower level. The best way of ensuring no interference would be to keep the pacs off at high altitude for a significant period. Certainly while crossing the peninsula. The last thing the perpetrator would have wanted would have been for someone to make a call or text from the plane. I am not saying that such a call / text would have been possible – just that the plan may have been to ensure it was impossible. In addition to phones, there are other potential ways a passenger could cause interference. There would be no way for the perpetrator to know that an off duty pilot / engineer was not a passenger.

2. Less chance of an intercept by a military plane. Again, it is fairly unlikely this could have been achieved even if MH370 had been low level. But high level makes it even less likely.

3. A low level flight would burn extra fuel which would limit the final leg south.

So if we assume the plane didn’t descend to low level crossing the peninsula and if we assume the pacs were kept off for a significant period of time, how much would that increase the maximum distance the plane could have flown by the time of fuel exhaustion? For the same endurance (i.e. the time of the final 7th handshake), fuel not burned crossing the peninsula at low level would have allowed a higher speed and a more southerly course to reach a point further SW on the arc.

The other piece of information that may be useful is the location of the solar terminator at the time of the 7th handshake. The terminator was some distance to the west of the current search area at that time. In order to have any chance of a semi-controlled ditching and minimising fragmentation and debris, the perpetrator would have needed some daylight. West of the terminator, the flight ended in darkness. East of the terminator, the flight ended in light.

So I would favor a location near the 7th arc, slightly to the east of the solar terminator at the time of the final handshake. This location would assume a higher speed (or a more direct track) than has been assumed thus far. Again, maybe there was no low-level flight across the Malaysian peninsula, and instead this fuel was available for a higher speed / greater distance south.

In short, I suepect the perpretator wanted to get as far away from anywhere as possible. I believe the plane had the fuel (and the daylight available) to go a bit further SW than the current search area.

Why would someone want do this? There are lots of possible reasons.

1. It has already become one of the greatest aviation mysteries ever

2. It has successfuly embarrassed Malaysia on the world stage

3. China is the country that makes Malaysia most nervous, and the country that Malaysia would wish not to upset. Most pax on MH370 were Chinese citizens.

4. If we didn’t have the Inmarsat data (and the perpretator was likely not aware of this), then we would be left with the following. An almost certain knowledge that the plane was stolen. A vague primary radar track heading WNW into the Indian Ocean towards various unfriendly places. And a plane with the range to reach them. That scenario would have been deeply disturbing to many governments and intelligence agencies.

________________________________________________________________________________________

Unplugged and moved on

 10. Feb, 2015 Text
No comment needed just get on with it!

Consultation Draft Proposed amendment to CAO 82.0 subsection 3A Nearly fifteen years since the issue was first broached…R20000040:

Quote:
SAFETY ACTIONAs a result of these occurrences, the Civil Aviation Safety Authority has commenced a project to review the fuel requirements for flights to remote islands.

Which in apparently nine years led to OS 09/13…

Project OS 09/13 – Fuel and Alternate requirements – Project approved. 21 Aug 2009

And with the PelAir ditching the project was expanded to include Aerial Work (Aeromedical flights) and then in July 2010 the NPRM 1003OS was released:

Quote:
3.3 Reasons for change3.3.1 The application of the additional remote island fuel requirements in CAO 82.0 which is currently limited to passenger-carrying charter operations was reviewed in the early stage of the project. As the safety of passengers is CASA’s highest priority, it was considered that excluding other passenger-carrying operations in the aerial work and RPT categories from the remote island fuel requirements had no justifiable safety
reasons.Note: The term “passenger” is defined in CAR 2 as meaning “any person who is on board an aircraft other than a member of the operating crew”. The term “operating crew” is defined in CAR 2 as meaning “any person who is on board an aircraft with the consent of the operator of the aircraft and has duties in relation to the flying or safety of the aircraft”.

Four years since then and all it took was this…

“..3A Conditions on all passenger-carrying aeroplane operations to remote islands
(1) Subject to paragraph (2), each certificate authorising 1 or more of the following operations in an aeroplane:
(a) charter operations for the carriage of passengers;
(b) regular public transport operations for the carriage of passengers;
(c) aerial work operations for ambulance functions or for functions substantially similar to ambulance functions (medical transport operations);
is subject to the condition that a passenger must not be carried under the certificate on a flight to a remote island unless:
(d) the aeroplane has more than 1 engine; and
(e) before the flight commences, the pilot in command has nominated an alternate aerodrome for the flight; and
(f) the nominated alternate aerodrome is not located on a remote island, unless CASA approves otherwise in writing; and
(g) when the flight commences the aeroplane is carrying not less than the minimum safe fuel for the flight; and
(h) during the flight, the pilot in command carries out in-flight fuel management to ensure that the aeroplane is always carrying sufficient fuel to enable it to reach its destination aerodrome as planned, or its nominated alternate aerodrome if necessary, with the required minimum fuel reserves intact.
(2) Paragraph 3A (1) applies to a medical transport operation whether or not a passenger is carried on the flight to a remote island.
(3) An approval under subparagraph (1) (f) may be subject to conditions…”

{Comment: Has to be one of the smallest amendments I’ve seen in the last 5 years or so..}

Hmm..it must have been a busy time for FF as July 2010 was also when the infamous CAIR 09/3 & Wodgers Weport were also released (reference my post #2035). And in fact CAIR 09/3 made mention of OS 09/13 at para 4.4

Strange how the ALIU had a slightly different take on how OS 09/3 was initiated??

Oh well good to see that someone in FF is finally taking the initiative to close the loop..

Wonder when the other part of the FF intended safety actions addressing the ATsB (closed) minor safety issue will eventuate…: AO-2009-072-SI-01

Quote:
Finally, CASA also advised of their intent to regulate Air Ambulance / Patient transfer operators as follows:

  • Air Ambulance/Patient transfer operations in the proposed operational Civil Aviation Safety Regulations (CASRs) will be regulated to safety standards that are similar to those for passenger operations.
  • While CASR Parts 138/136 will be limited to domestic operations and, if CASA decides to retain Air Ambulance/Patient transfer operations in these rule suites, any such operation wishing to operate internationally will also be required to comply with CASR Part 119. If, however, CASA decides to move these operations into CASR Parts 121/135/133 they will already be required to comply with CASR Part 119. Either way, Air Ambulance/Patient transfer operations will be regulated to the same standard as Air Transport Operations (ATO). In relation to Norfolk and Lord Howe Islands, all ATO which include Air Ambulance/Patient transfer, will be required to carry mainland alternate fuel.
  • CASR Parts 119/121/135/133 are expected to be finalised by the end of 2012 and are currently proposed to commence in June 2014. CASR Parts 138/136 are expected to be made by June 2013 and are proposed to commence in June 2014. Given that the drafting of these CASR Parts are subject to third party arrangements (Attorney-General’s Department) and CASA and the industry’s ability to effectively implement the new rule suite, these timelines are subject to change.

Hopefully we won’t have to wait another fifteen years for that to happen..

MTF…

Part One- The inconvenience of facts & timelines??

Again, although much belated, I applaud the initiative of FF team OS 09/13 to bring fwd, in an obvious period of uncertainty, the Consultation Draft Proposed amendment to CAO 82.0 subsection 3A

Quote:
Purpose/Objectives
The CAO amendment would add Cocos (Keeling) Island to the list of existing remote islands (which are Christmas, Lord Howe and Norfolk Islands).
The amendment would substitute a new subsection 3A, which provides that each AOC for passenger-carrying charter, RPT operations, or for aerial work ambulance-type functions (medical transport operations) is subject to the condition that a passenger must not be carried to a remote island unless the following requirements are complied with:
a. the aeroplane is multi-engined
b. the pilot has nominated an alternate aerodrome
c. that alternate aerodrome is not itself on a remote island (unless CASA specifically approves)
d. the aeroplane is carrying not less than the minimum safe fuel for the flight
e. during the flight, the pilot in command carries out in-flight fuel management to ensure that the aeroplane is always carrying sufficient fuel to enable it to reach its destination aerodrome as planned, or its alternate aerodrome (if necessary) with the required minimum fuel reserves intact.
In some medical transport operations, medical and nursing staff may not be considered as ‘passengers’ (for example, because they have flight safety duties to perform). To protect the safety of such personnel who are, in effect, third parties like passengers, for medical transport operations the safety requirements described above would apply whether or not a ‘passenger’ is carried on the flight to a remote island.

…it maybe small consolation but I am sure Ziggychick and others will appreciate your efforts…

However, at the same time, I am extremely intrigued by certain aspects in the history of project OS 09/13 (Project OS 09/13 – Fuel and Alternate requirements Consultation history ).

So in an effort to join the dots let us start with the 15 July 2010 NPRM webpage (click here ). In the NPRM 1003 OS pdf in the foreword it was stated…

“I would like to thank you for expressing interest in this proposal and emphasise that no rule changes will be undertaken until all NPRM responses and submissions received by the closing date 9 September 2010 have been considered…”

And on previous page…

“…Following consideration of responses to this NPRM, CASA will prepare a Summary of Responses, and make revisions to the draft CAO amendment where considered appropriate.

CASA will conduct further analysis of the extent of the impact these changes will have on operators and pilots to ensure an adequate timeframe is given for implementation. It is envisaged that a transition period of 3 to 6 months will be allowed to ensure operators have revised procedures in respect to these changes…”
Now to the man at the back of the room the obvious question is WTF happened to NPRM 1003 OS in the interim period of nearly four years?? Do FF seriously expect the MATBOTR to accept this as an excuse…
“…Under Notice of Proposed Rule Making (NPRM) 1003OS (published in July 2010) the Civil Aviation Safety Authority (CASA) proposed changes to Civil Aviation Order (CAO) 82.0 to include Cocos (Keeling) Island as a designated remote island…
CASA Project OS 09/13 was re-phased to allow for the inclusion of the International Civil Aviation Organization (ICAO) Standards and Recommended Practices (SARPs) developments relating to…
…With the SARP now effective, and the ICAO Fuel and flight Planning Manual (FFPM) finalised, these standards are being drafted into the Civil Aviation Safety Regulations 1998 (CASR). CASA now considers it appropriate to start to bring forward some aspects into the CAOs and the Civil Aviation Regulations 1988 (CAR) prior to the making of the Operational CASR Parts…”
Moving onto Annex A – Proposed Amendment to CAO 82.0 – Air Operators’ Certificates. And a quick comparison between the 2010 & 2014 versions of the proposed amendments to CAO 82.0.

2010 version:

I, JOHN FRANCIS McCORMICK, Director of Aviation Safety, on behalf of CASA, make this instrument under paragraph 28BA (1) (b) and subsection 98 (4A) of the Civil Aviation Act 1988.

John F. McCormick
Director of Aviation Safety
July 2010
Civil Aviation Order 82.0 Amendment Order (No. 1) 2010
1 Name of instrument
This instrument is the Civil Aviation Order 82.0 Amendment Order (No. 1)
2010.
2 Commencement
This instrument commences [3 to 6 months after registration].
3 Amendment of Civil Aviation Order 82.0
Schedule 1 amends Civil Aviation Order 82.0.
Schedule 1 Amendments
[1] Paragraph 2.1, new definition, minimum safe fuel
insert minimum safe fuel has the meaning given by paragraph 2.3.
[2] Paragraph 2.1, definition of remote island
substitute remote island means:
(a) Christmas Island; or

(b) Cocos (Keeling) Islands; or

(c) Lord Howe Island; or

(d) Norfolk Island.

[3] Paragraph 2.1, new definition of reserve fuelinsert reserve fuel means the variable fuel reserve and the fixed fuel reserve to be carried by an aircraft in accordance with guidelines issued by CASA for

subparagraph 234 (3) (d) of the Civil Aviation Regulations 1988.
[4] Paragraphs 2.3, 2.4 and 2.4.1
substitute
2.3 Unless CASA approves otherwise in writing for a particular flight, the
minimum safe fuel for an aeroplane undertaking a flight to a remote island is the greater of the following:
(a) the total of:

(i) the minimum amount of fuel that would enable the aeroplane to fly,with all engines operating, to the remote island aerodrome and then to

the nominated alternate aerodrome; and
(ii) reserve fuel;
(b) the total of:
(i) the minimum amount of fuel that would enable the aeroplane to do the
following if a critical event were to occur at the most critical point of
the flight:
(A) fly to its destination aerodrome, or an alternate aerodrome;
(B) fly above the aerodrome for 15 minutes at 1 500 feet at holding
speed under standard temperature conditions;
(C) land at the aerodrome; and

(ii) reserve fuel
2.3.1 For paragraph 2.3, a critical event for an aeroplane means:
(a) the failure of an engine; or
(b) a loss of pressurisation in the aircraft; or
(c) both the failure of an engine and a loss of pressurisation in the aircraft.

2.3.2 An approval under paragraph 2.3 may be given with or without conditions.

2.4 An amount of fuel mentioned in paragraph 2.3 is to be worked out:
(a) for an aeroplane that is a transport category aircraft, by using:
(i) the performance data and the fuel consumption data contained in the
aeroplane’s flight manual; or
(ii) the performance data and the fuel consumption data obtained from a

flight test of the aeroplane carried out in an approved manner; or
(b) for an aeroplane that is not a transport category aircraft, by using:
(i) the following:
(A) the performance data for the aeroplane provided by the
manufacturer of the aircraft’s airframe, or contained in the
aeroplane’s flight manual or the pilot’s operating handbook for the aeroplane; and
(B) the fuel consumption data for the aeroplane obtained from 1 of the
sources mentioned in sub-sub-subparagraph (A),or provided by the
manufacturer of the aeroplane’s engines; or

(ii) the performance data and the fuel consumption data obtained from a flight test of the aeroplane carried out in an approved manner.
2.4.1 For sub-subparagraphs 2.4 (a) (i) and 2.4 (b) (i), if the issue of a supplemental type certificate for an aeroplane has the effect of amending the performance data or the fuel consumption data referred to in the sub-subparagraphs, the amended performance data or fuel consumption data must be used.

[5] Subsection 3A
substitute

3A Conditions on all passenger-carrying aeroplane operations to remote islands
(1) Unless CASA approves otherwise in writing, each certificate authorising aerial work, charter or regular public transport operations in an aeroplane is subject to the condition that a passenger may be carried under the certificate on a flight to a remote island only if:

(a) the aeroplane has more than 1 engine; and
(b) at the start of the flight, not less than the minimum safe fuel is carried by
the aeroplane for the flight; and(c) before the flight commences, the pilot in command has nominated an alternate aerodrome for the flight; and
(d) the nominated alternate aerodrome is not located on a remote island.
(2) An approval under paragraph (1) may be given with or without conditions.
Note 1 Under subregulation 2 (1) of the Civil Aviation Regulations 1988, passenger means any person who is on board an aircraft other than a member of the operating crew
Note 2 Subsection 3A, read with paragraph 2.3, means that an AOC holder may not conduct an aeroplane operation carrying a passenger to a remote island except in a multi-engine aeroplane, whose pilot in command has nominated an appropriate alternate aerodrome for the flight, and which at take-off is carrying sufficient fuel to reach the destination aerodrome and then the nominated alternate aerodrome without using any reserve fuel.
[6] Appendix 5, after subclause 6 (3)
insert
(4) If subsection 3A applies to an AOC holder for an aeroplane conducting an
EDTO flight, then:
(a) the amount of fuel calculated for subclause (2) must be not less than the
minimum safe fuel; and
(b) the operations manual must include the calculation of the minimum safe
fuel.
Note Subsection 3A deals with passenger-carrying aeroplane operations to remote islands.
Remote island, reserve fuel and minimum safe fuel are defined terms under this Order.
2014 version:
I, JOHN FRANCIS McCORMICK, Director of Aviation Safety, on behalf of CASA, make this instrument under paragraph 28BA (1) (b) and subsection 98 (4A) of the Civil Aviation Act 1988.
John F. McCormick Director of Aviation Safety
[DATE] 2014Civil Aviation Order 82.0 Amendment Order (No. 1) 2014
1 Name of instrument
This instrument is the Civil Aviation Order 82.0 Amendment Order (No. 1) 2014.2 Commencement
This instrument commences on the day after registration.
3 Amendment of Civil Aviation Order 82.0Schedule 1 amends Civil Aviation Order 82.0.
Schedule 1 Amendments

[1] Paragraph 2.1, definitions substitute

remote island means:
(a) Christmas Island; or
(b) the Cocos (Keeling) Islands; or
(c) Lord Howe Island; or
(d) Norfolk Island.
[2] Subsection 3A substitute
3A Conditions on all passenger-carrying aeroplane operations to remote islands (1) Subject to paragraph (2), each certificate authorising 1 or more of the following operations in an aeroplane:

(a) charter operations for the carriage of passengers;

(b) regular public transport operations for the carriage of passengers;

(c) aerial work operations for ambulance functions or for functions substantially similar to ambulance functions (medical transport operations);is subject to the condition that a passenger must not be carried under the certificate on a flight to a remote island unless:

(d) the aeroplane has more than 1 engine; and(e) before the flight commences, the pilot in command has nominated an alternate aerodrome for the flight; and

(f) the nominated alternate aerodrome is not located on a remote island, unless CASA approves otherwise in writing; and
(g) when the flight commences the aeroplane is carrying not less than the minimum safe fuel for the flight; and

(h) during the flight, the pilot in command carries out in-flight fuel management to ensure that the aeroplane is always carrying sufficient fuel to enable it to reach its destination aerodrome as planned, or its nominated alternate aerodrome if necessary, with the required minimum fuel reserves intact.

(2) Paragraph 3A (1) applies to a medical transport operation whether or not a passenger is carried on the flight to a remote island.

(3) An approval under subparagraph (1) (f) may be subject to conditions

{Note: Still reviewing the subtle differences in para 3A but the obvious difference is that the 2014 version is much more condensed and provides a more distinct definition of MTO flights with the addition of sub para (2).}Q. What happened to the 2010 responses which in the normal NPRM due process are usually published??Still joining the dots…

Part two to follow…

ps Interesting how Phase One & Two (as quoted below) from today’s version of OS 09/13 is at odds with the CAIR 09/3 version (see post #2188)…

Quote:
Phase 1 will involve amendments to the relevant Civil Aviation Orders (CAOs) and a review of CAAP 234-1 for flights to Isolated Aerodromes in light of the ICAO amendments. This phase will encompass fuel and operational requirements for flights to Isolated Aerodromes. The review will also consider the provision for flight to an alternate aerodrome from a destination that is a designated Isolated Aerodrome. The CAAP234-1 will also be expanded to provide guidance and considerations necessary for flights to any Isolated Aerodrome, in particular when, and under what circumstances, a pilot should consider a diversion.
Quote:
Phase 2 will involve amendments to the relevant Civil Aviation Orders (CAOs) and further review of CAAP 234 in light of the ICAO amendments. This phase will encompass regulatory changes related to the implementation of general fuel planning, in-flight fuel management and the selection of alternate aerodromes. This review will include the methods by which pilots and operators calculate fuel required and fuel on-board.

Last edited by Sarcs; 15th Aug 2014 at 15:49.

 Is Sarcs Morriarty reincarnated?

Quote:
Sarcs #2190 – “Still joining the dots..”
Quote:
Thorny – “Sarcs, mate, you really are a cynical Bast..ard”

Not only that! – he’s being very mischievous and setting up a weekend heads-scratcher; but I reckon he’s also trying to sneak a late entry into the Senate Ordinance Cup ; which makes him a devious, crafty SOB…..

I’m going to call his bluff; there is a possible entrant from overseas, little known in Oz but if the connections decide that they will run the horse, it will alter the odds. So let’s see, (looking – looking) Ah, howzabout – Canadian Club; horse, out of Federal Plod by Criminal Intent.

You see, I reckon Sarcs has ‘inverted’ the perspective and instead of wondering why the Canadian form guide has not been published; he has tracked the MoP, backwards; from the Canadian TSB audit point of view i.e. What the CTSB would see when they investigate ICAO compliance. In that context, if Sarcs has started from the compliance with ICAO annex 13 end and worked backwards through to the ubiquitous MoU. Could the CTSB possibly feel that the MoU disturbs the ICAO tenet of ATSB ‘sovereignty’ during an investigation and the righteous issuing of Safety Recommendations? Could this notion naturally lead to examining the dramatic drop of the Safety Recommendations (SR) from ‘Serious’ to ‘Minor’? In short, have the Pel Air books been ‘cooked’?

In a honest world, the MoU should work just fine; ATSB notifies CASA that SR are incoming; the FF ‘White hats’ grab the spell book and start weaving – preparing a proper response. All good until it was realised CASA were going to have ‘egg on their face’, had the ATSB not backed down. Perhaps that ‘GWM report’ was prepared to riposte the ATSB brick bat. “We’re on top of this” says Sleepy Hollow.

The consensus (among the BRB) is that the CASA ‘White hats’ receiving information through the MoU were preparing for a ‘serious safety’ call from the ATSB on three issues; (1) the serious lack of CASA action on CDP on 82.0; and, (2) CASA oversight of the operator; (3) against the operator.

Enter the FF Black hats – Instead of timely advice being used to prepare the way for a much delayed ‘fuel policy’ changes; the good intentions of the MoU pave the merry road to perdition. The Black hats take the early advice and set about ‘subverting’ it so that the mighty blow the ATSB was intending to deliverer became little more than a gentle ‘well done’ pat on the back. There is good support information for this to be had from the total lack of action taken on ATSB, Coronial and many other ‘safety’ related recommendations and there is no closed loop system for tracking, auditing or examining those changes. There is certainly no system for audit of those changes – refer CRM 82 time line. What is it now 20 years ? bad law Reg 206 and RFDS and etc. etc. What a witches brew..small wonder ‘white hats’ leave in droves.

The disconnect is clear enough from the Sarcs post above. Has the benefit of the MoU been grossly misused to undermine the ATSB ‘sovereign’ authority under the ICAO?; the ‘disturbance’ of the TSI Act is clearly apparent. If the AFP investigation and the Canadian audit turned up the same conclusions; possibly two things would happen (1) the minuscule would ‘sit’ on the CTSB report (2) the AFP information prompted Heffernan, Stearle and Xenophon to bring on the MoP. The latest gossip ‘on the breeze’ is that the PM’s department is actively involved (Choc frog Sunny) and that the TSB ‘report’ is in town but the minuscule has deemed it ‘low priority’.

It’s a bit of a stretch but could the exposed, cynical manipulation of Pel-Air be parlayed in criminal charges? If that eventuates will Chambers and White along with McComic and possibly Sangston need a little ‘legal’ advice?

Sarcs you research daemon, let’s have a look at part two. It’s cruel to torment a curiosity bump (or hump). You can sing the verse below using the –

– as a tune – quite catchy, ain’t it…

The sexual life of the camel
Is stranger than anyone thinks.
At the height of the mating season
He tries to bugger the Sphinx.
But the Sphinx’s posterior orifice
Is clogged by the sands of the Nile,
Which accounts for the hump on the camel
And the Sphinx’s inscrutable smile.

What the hell – it’s Saturday, ain’t it? Toot toot..


Last edited by Kharon; 16th Aug 2014 at 14:05. Reason: I curse Google Chrome – no smilies = bummer…Hey fixed it Yay!!!

Post ditching (1734 days & counting) – In the eyes of the investigator.

Kharon:

Quote:
Could the CTSB possibly feel that the MoU disturbs the ICAO tenet of ATSB ‘sovereignty’ during an investigation and the righteous issuing of Safety Recommendations? Could this notion naturally lead to examining the dramatic drop of the Safety Recommendations (SR) from ‘Serious’ to ‘Minor’? In short, have the Pel Air books been ‘cooked’?

Bugger “K” stole my thunder… …oh well relegated to gap filler yet again…

Ok before we start working through the ‘timeline of embuggerance’ (TOE) an update on the MoP Stakes from the Senate: Possible imposition of a penalty on a witness before the Rural and Regional Affairs and Transport References Committee or a person providing information to the committee

{Note the Committee Senators (Stewards) membership includes one loud, outspoken BIG MACK}

Kharon:

Quote:
In a honest world, the MoU should work just fine; ATSB notifies CASA that SR are incoming; the FF ‘White hats’ grab the spell book and start weaving – preparing a proper response. All good until it was realised CASA were going to have ‘egg on their face’, had the ATSB not backed down. Perhaps that ‘GWM report’ was prepared to riposte the ATSB brick bat. “We’re on top of this” says Sleepy Hollow.

In the eyes of the TSBC: It would first be prudent to refer to what we know they have been scoped to review in regards to PelAir. From ATSB AQON 4 Senate Estimates (24/02/14) RED said:

The Transportation Safety Board of Canada (TSB) has agreed to review the ATSB’s investigation methodologies and processes. Specifically, the review is examining the ATSB’s:
• Investigation methodology and its application
• Management and governance in relation to investigations
• Process for compiling an investigation report
• Approach to communicating with persons and organisations external to the ATSB in relation to an investigation

As part of the review, the TSB has undertaken to examine the application of the ATSB methodologies to the Norfolk Island investigation and two others.
The review was instigated in response to Senate References Committee criticisms that the ATSB investigation of the Norfolk Island accident did not comply with the requirements of ICAO Annex 13 or the ATSB’s written standards. The review is also intended as part of the ATSB response to Inquiry recommendations concerning the adequacy of the ATSB’s investigation policies, procedures and training.

The exercise is not a reinvestigation of the occurrence, and hence the TSB has not sought to reinterview involved parties. Howevers part of eviewing the ATSB’s investigations, the statements and other evidence of involved parties have been available to the review team.

Therefore it would be safe to assume that the TSBC would be reviewing most, if not all, the published under privilege documentation from the Senate AAI inquiry, which would include the following 2 documents:

1. Correspondence from the ATSB to CASA regarding a critical safety issue, received 22 October 2012;(PDF 2663KB)
2. Internal ATSB email regarding the ATSB and CASA’s approach to the Pel-Air investigation (dated 9 February 2010), received 10 October 2012;(PDF 1093KB)

As RED indicates the TSBC will review the PelAir report against the recognised international standards for AAI (as outlined in ICAO Annex 13) and not on any domestic arrangements i.e. the MoU.

On the subject of safety issues identified, in the course of an investigation, by the AAI as needing prompt action and a SR promulgated Annex 13 states:

Quote:
Safety recommendations
6.8 At any stage of the investigation of an accident or incident, the accident or incident investigation authority of the State conducting the investigation shall recommend to the appropriate authorities, including those in other States, any preventive action that it considers necessary to be taken promptly to enhance aviation safety.6.9 A State conducting investigations of accidents or incidents shall address, when appropriate, any safety recommendations arising out of its investigations to the accident investigation authorities of other State(s) concerned and, when ICAO documents are involved, to ICAO.RESPONSIBILITY OF A STATE RECEIVING
SAFETY RECOMMENDATIONSAction on safety recommendations
6.10 A State that receives safety recommendations shall inform the proposing State of the preventive action taken or under consideration, or the reasons why no action will be taken.Note — Nothing in this Standard is intended to preclude the State conducting the investigation from making proposals for preventive action other than safety recommendations.

The ATsB intent to compliance with the Annex is outlined in s25A of the TSI Act.

So in terms of 1. (Attachment one above) the TSBC would give the ATsB its 1st tick i.e. the investigators have identified a CSI and have basically
written a DRAFT of the soon to be notified SR. However it would probably be seen as passing strange, not normal practice, that the ATsB are essentially giving the intended SR addressee a ‘heads up’.

Quote:
I refer to the meeting between officers of the Civil Aviation Safety Authority (CASA) and Australian Transport Safety Bureau (ATSB) that took place by video conference on 3 February 2010, and agreed that a critical safety issue existed in respect ofthe lack of regulation or guidance for pilots when exposed to previously unforecast meteorological conditions on long flights to destinations with no nearby alternates. An outcome of that meeting was that a number of the CASA participants indicated that they understood the issue, and that it should be progressed with CASA management.

But maybe this is a good initiative because the letter does goes on to say…

“….In later telephone calls to me, you suggested that the receipt of this letter would allow you to ‘kick-start’ CASA’s consideration of, and response to the issue.

Attachment One describes the nature of the critical safety issue that was identified as a result of the ATSB’s initial investigative work in respect of the above accident, and formed the basis of our discussions on 3 February 2010. CASA’s commitment to address the safety issue is appreciated…”

And indeed the ‘White Hats’ (as “K” calls them) stepped into action and started proactively addressing what they assumed would soon be a published ATsB SR, published an update to OS 09/13 (see 4.4 of CAIR 09/3) and started writing NPRM 1003 OS.

So maybe the TSBC would have given the ATsB leeway and understood that in the interests of better relations (as this was seen as a test case for the newly just minted MoU), that this little divergence from SOP could be advantageous.

However on reading the internal email at 2. this acceptance of diverging from SOP IMO would have come to a resounding conclusion (crash):

Quote:
We were discussing the potential to reflect the intent of our new MoU that describes the 2 agencies as ‘independent but complementary’. We discussed the hole that CASA might have got itself into by its interventions since the ditching, and how you might have identified an optimum path that will maximise the safety outcome without either agency planting egg on the other agency’s face.Right now, I suspect that CASA is entrenching itself into a position that would be hard to support. If we were to contemplate an exit strategy, or an ‘out’, then CASA would need to recognise that it is ‘in’ something in the first place. This is my take of how I see their position at the moment.
When the aircraft ditched, both the flight crew and the operator stopped their Westwind Aeromedical operations.CASA coached and guided the operator very well as they collaborated to develop a much safer process to avoid a repetition of this accident. This has happened, and Pei-Air are now operating again. The same thing hasn’t happened to the flight crew. While they may not have been the ‘Aces of the base’, they were following the relevant procedure provided by both CASA and their operator. This is an opportunity for CASA to follow the same approach with the flight crew as they have done with the operator.As a systemic investigator, we see 3 separate slices of ‘Reason cheese’ with aligned holes ( flight crew, operator & rule-maker), and we want to seal all those holes. The operator has now been realigned, and I think CASA has done a very good job in helping them. For the flight crew, they do need realigning to ensure they now meet the updated Ops manual requirements. For the rule-maker, I would be extremely satisfied if they then proactively realigned everybody’s understanding of this operational risk, and how it can be managed in the future.As we discussed yesterday, following the ditching, everything went (metaphorically) ‘up in the air’. CASA has done a good job in realigning Pei-Air while it was still in the air so that it returned to earth with a much better take on how to manage this risk.Unfortunately, they took action on the flight crew without first contemplating their end-game. If they reframe their pre-emptive action with the flight crew to show that they had managed all the levels of safety management by simply putting the pilots’ permissions to fly on hold until they had found the problem and remedied it, then they would look far better than if they tried to prosecute the probably indefensible and hardly relevant.

We will be telling this story in our final report, if not earlier, so why not make the most of this opportunity for both agencies to publicly work harmoniously, in a parallel direction?

IMO any good TSBC investigator could well relate and be most disturbed by the angst that this fellow investigator was feeling at this point in time. The massive conflict of interest is beyond obvious and directly in contravention of the spirit & intent of Annex 13.

Hmm…think I’m going to have to have more parts to this as I’ve just discovered a couple more errant dots and I’m yet to look through the eyes of the other investigator…

MTF…